Abstract
Objective: To review a case series of 12 women with unexpected heart and lung disorders that occurred during pregnancy and the puerperium, describing for teaching purposes the pitfalls in practice and the lessons learned from this experience. Materials & Methods: We reviewed case files of women with medical and/or hypertensive complications of pregnancy that were evaluated for medicolegal defense purposes by the first author between 1986-2015. Twelve women in these case files experienced unexpected cardiovascular and/or cardiopulmonary complications late in pregnancy or early in the puerperium. For each case, the pertinent medical record information was extracted. Important concepts as lessons learned are summarized and referenced for teaching purposes. Results: Five women had undetected preexisting heart disease which acutely deteriorated during the third trimester, four women developed postpartum heart failure related to pregnancy and delivery, and three women suffered an intrapartum cardiac arrest; none survived. Their case presentations illustrate the importance of obstetric health care professionals being alert to the signs/symptoms of developing cardiopulmonary disease late in pregnancy and following delivery so that timely evaluation and intervention can be accomplished to potentially avoid morbidity and mortality. Diagnostic categories include peripartum heart failure, high-risk chronic hypertension, superimposed preeclampsia, amniotic fluid embolism, pulmonary embolism and Raynaud’s with occult pulmonary hypertension. Conclusion: These cases illustrate the diversity of ways that cardiovascular disease can suddenly complicate pregnancy and the early postpartum period. A major part of any effort to enhance safer motherhood is a heightened awareness by obstetric specialists to consider the possibility of heart disease in all maternity patients so that appropriate consultation and collaboration with other specialists might help avoid major maternal morbidity or mortality.
Highlights
The 2018-2019 ACOG Presidential Task Force on Pregnancy and Heart Disease resulted in the 2019 publication of the ACOG Practice Bulletin on this important clinical issue [1]
The rising trend in maternal deaths related to cardiovascular disease appears to be due primarily to acquired heart disease, unknown and/or silent until late in pregnancy or in the days and weeks immediately following delivery
Clinician issues include the challenges to sustaining a high level of suspicion and expectation that any pregnant or postpartum patient can have a significant underlying cardiac disorder especially if they exhibit any of the four key heart disease risk factors of black race, obesity, hypertension or age over 40
Summary
The 2018-2019 ACOG Presidential Task Force on Pregnancy and Heart Disease resulted in the 2019 publication of the ACOG Practice Bulletin on this important clinical issue [1]. Its impact upon enhanced pregnancy and postpartum care by obstetric specialists in the United States has yet to be measured, but its importance to obstetric practice is underscored by the sobering statistic that cardiovascular diseases are responsible for 26.5% of U.S pregnancy-related deaths [2]. Key to reducing maternal mortality and major maternal morbidity in the United States is the need to improve patient outcomes for women who develop any form of new-onset heart disease during pregnancy and postpartum. Our purpose in this investigation of 12 cases is to explore how cardiovascular/acquired heart disease can present to the obstetric health care professional, to determine how often one or more of the 4 key risk factors (Black, hypertensive, obese, maternal age > 40) for heart disease in pregnancy are present, and to make a determination if consideration of the diagnosis of CVD might have averted the outcome
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